Prescription Form and Administration record for CosmoFer®
(Low molecular weight iron III dextran) infusion to adult patients
Space for patient addressograph
Patient Name…………………………………….
Hospital Number…………………………………
Date of Birth………………………………………
Ward: …………………………………
Consultant: …………………………...
Patient weight (kg): …………………..
Height ………… IBW if >90kg:………
Haemoglobin level (g/l): ………………
The risk of serious hypersensitivity reactions with intravenous (IV) iron
All IV iron products can cause serious hypersensitivity reactions which can be fatal. The risk of
sensitivity is increased in patients with known allergies, immune or inflammatory conditions as
well as patients with a history of severe asthma, eczema or other atopic allergy. IV iron products
should not be used during pregnancy unless clearly necessary. Patients should be informed by the
prescriber of the risk of hypersensitivity before each administration and the relevant symptoms.
Dosage required
The dose and dosage schedule for CosmoFer® must be individually calculated for each patient
based on a calculation of the total iron deficit. Please see the Policy for the Prescribing,
Preparation and Administration of IV iron products for details of contraindications and
precautions.
Calculation of dose
Indication (please tick one)-  blood loss
 anaemia
Iron stores should be taken into account for patients with iron deficiency anaemia. Iron stores do
not have to be replaced when the iron deficit is due to blood loss.
Total iron deficit (mg) =
[body weight (kg) x (Target Hb -Actual Hb)(g/l) x 0.24] + mg iron stores
= [ …………kg x ( ……….. - ………….) x 0.24] + ………….mg
= …………..mg
For patients above 35kg target Hb 150 g/l with iron stores of 500mg.
For patients 35kg or less, target Hb 130 g/l with iron stores of 15mg/kg.
For patients >90kg use Ideal Body Weight.
For pregnant patients target Hb 110 g/l and pre-pregnancy weight should be used.
Prescription
The maximum dose of iron that can be administered as a single infusion is 20mg/kg body
weight. If the dose to be administered is greater than 20mg/kg then the dose must divided into
multiple weekly administrations.
TOTAL DOSE OF IRON = ……………..…mg to be administered over ……….. weeks.
Date
Dose to be Volume to be given over 15 Pharmacy
Administered
administered
minutes initially (see over)
prepared by
by
(500ml ÷ dose of Cosmofer mg) x 25mg
= ………… millilitres
(500ml ÷ dose of Cosmofer mg) x 25mg
= ………… millilitres
Patient provided with a service leaflet for IV iron products (please tick) 
Signature of prescribing Consultant/Registrar…………………………………..Date:………………
Cosmofer Prescription V_2.0 Created: June 2015 Date of review: June 2017
Administration
The Cosmofer® infusion should be given by the intravenous route via an infusion pump. A test
dose is not required however the first 25mg of the infusion should be administered over 15
minutes to reduce the incidence of reaction. This can be calculated using the following equation;
(500ml ÷ Dose of Cosmofer mg) x 25mg = millitres to be given over 15 minutes initially
The total dose is given by infusion over 4-6 hours (rate of infusion gradually increased to
125ml/hr over 4 hours or 83ml/hr over 6 hours).
The total dose of iron will be prepared in 500ml sodium chloride 0.9%. Cosmofer® infusions can
also be prepared in dextrose 5 % on request.
Monitor the patient during the infusion and for 30 mins after each administration of an IV iron
product. IV iron products should only be administered when staff trained to evaluate and manage
anaphylactic/ anaphylactoid reactions as well as resuscitation facilities are immediately available.
Patients should be monitored for signs or symptoms of anaphylaxis, mild allergic reactions,
hypotension and extravasation.
Preparation
Cosmofer® infusions will normally be prepared the day before treatment, therefore the
presciption must be received in pharmacy in advance. For same day requests of Cosmofer®
please contact pharmacy on extension 4880 to check capacity prior to prescribing.
PLEASE RETAIN A COPY OF THIS SHEET IN THE PATIENTS NOTES AS A
RECORD THAT THEY HAVE RECEIVED PARENTERAL IRON.
Cosmofer Prescription V_2.0 Created: June 2015 Date of review: June 2017